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Perioperative Outcomes and Surgical Case Volume in Pediatric Complex Cranial Vault Reconstruction: A Multicenter Observational Study From the Pediatric Craniofacial Collaborative Group

Fernandez, Allison M. MD, MBA*; Reddy, Srijaya K. MD, MBA; Gordish-Dressman, Heather PhD; Muldowney, Bridget L. MD§; Martinez, José Luis MD; Chiao, Franklin MD; Stricker, Paul A. MD#; Abruzzese, Christopher; Apuya, Jesus; Beethe, Amy; Benzon, Hubert; Binstock, Wendy; Brzenski, Alyssa; Budac, Stefan; Busso, Veronica; Chhabada, Surendrasingh; Cladis, Franklyn; Claypool, Danielle; Collins, Michael; Dabek, Rachel; Dalesio, Nicholas; Falcon, Ricardo; Fernandez, Patrick; Fiadjoe, John; Gangadharan, Meera; Gentry, Katherine; Glover, Chris; Goobie, Susan M.; Gosman, Amanda; Grap, Shannon; Gries, Heike; Griffin, Allison; Haberkern, Charles; Hajduk, John; Hall, Rebecca; Hansen, Jennifer; Hetmaniuk, Mali; Hsieh, Vincent; Huang, Henry; Ingelmo, Pablo; Ivanova, Iskra; Jain, Ranu; Kars, Michelle; Kowalczyk-Derderian, Courtney; Kugler, Jane; Labovsky, Kristen; Lakheeram, Indrani; Lee, Andrew; Masel, Brian; Medellin, Eduardo; Meier, Petra; Mitzel Levy, Heather; Muhly, Wallis T.; Nelson, Jonathon; Nicholson, Julie; Nguyen, Kim-Phuong; Nguyen, Thanh; Olutuye, Olutoyin; Owens-Stubblefield, Margaret; Ramesh Parekh, Uma; Petersen, Timothy; Pohl, Vanessa; Post, Julian; Poteet-Schwartz, Kim; Prozesky, Jansie; Reid, Russell; Ricketts, Karene; Rubens, Daniel; Ryan, Laura; Skitt, Rochelle; Soneru, Codruta; Spitznagel, Rachel; Singh, Davinder; Singhal, Neil R.; Sorial, Emad; Staudt, Susan; Stubbeman, Bobbie; Sung, Wai; Syed, Tariq; Szmuk, Peter; Taicher, Brad M.; Thompson, Douglas; Tretault, Lisa; Ungar-Kastner, Galit; Watts, Rheana; Wieser, John; Wong, Karen; Zamora, Lillian; on behalf of The Pediatric Craniofacial Collaborative Group

doi: 10.1213/ANE.0000000000003515
Pediatric Anesthesiology: Original Clinical Research Report

BACKGROUND: Complex cranial vault reconstruction (CCVR) performed to treat craniosynostosis can be associated with significant blood loss, transfusion, and perioperative complications. The aim of this study was to examine the effect of CCVR surgical case volume on perioperative outcomes. We hypothesized that surgical case volume is not associated with differences in perioperative outcomes. The study primary outcome was total perioperative blood donor exposures. Secondary outcomes included the total perioperative transfusion volume, major complications, and intensive care unit and hospital length of stay.

METHODS: The multicenter Pediatric Surgery Perioperative Registry was queried for infants and children undergoing CCVR between June 2012 and September 2016. Institutions were categorized into low, middle, or high surgical case volume groups based on tertiles of the average number of cases performed per month. Primary and secondary outcomes were analyzed with respect to these groupings.

RESULTS: The query yielded 1814 CCVR cases from 33 institutions. Demographics were similar among the 3 study groups. An inverse relationship between surgical case volume and total perioperative blood donor exposures was observed (P < .001). The low-volume group had higher perioperative transfusion volumes (P = .02 versus middle; P = .01 versus high). There was no significant relationship between surgical case volume and the incidence of major postoperative complications or hospital length of stay.

CONCLUSIONS: In this study, low surgical case volumes were associated with increased total blood donor exposures and increased perioperative transfusion volumes. Hospital length of stay was homogeneous in the 3 groups, suggesting a limited overall clinical impact of the observed transfusion outcome differences.

From the *Department of Anesthesia, Perioperative and Pain Medicine, Johns Hopkins All Children’s Hospital, St Petersburg, Florida

Department of Anesthesiology, Monroe Carell Jr Children’s Hospital/Vanderbilt University Medical Center, Nashville, Tennessee

Center for Translational Science, Children’s National Health System/The George Washington University School of Medicine and Health Sciences, Washington, DC

§Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

Department of Pediatric Anesthesia, CHU Sainte-Justine/University of Montreal, Montreal, Québec, Canada

Department of Anesthesiology, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York

#Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.

Published ahead of print 5 March 2018.

Accepted for publication May 3, 2018.

Funding: Departmental.

The authors declare no conflicts of interest.

A full list of contributors can be found at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Allison M. Fernandez, MD, MBA, Department of Anesthesia, Perioperative and Pain Medicine, Johns Hopkins All Children’s Hospital, 501 6th Ave S, St Petersburg, FL 33701. Address e-mail to

Copyright © 2018 International Anesthesia Research Society
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